The impact of intensive counselling and a mass media campaign on complementary feeding practices and child growth in Bangladesh

What we know: In Bangladesh there has been little to no progress in improving children’s diets and little evidence available on what works to improve maternal knowledge and practices related to complementary feeding (CF).

What this article adds: A cluster-randomised impact evaluation compared the impact of two ‘Alive and Thrive’ intervention packages (one intensive, one less intensive) on CF practices and anthropometric outcomes, delivered at scale (1.7 million mothers in 50 sub-districts) over a four-year period. A cross-sectional household survey of feeding practices (6-23.9 months) and stunting prevalence (24-47. 9 months) was conducted at baseline and endline. Core WHO CF indicators improved over time (P < 0.0001 for all indicators) in both groups. For all CF indicators except timely introduction of solid, semi-solid or soft foods, the increases were significantly higher in the intensive group and achieved levels were high. Stunting declined significantly in all children 24-47.9 months of age and did not differ significantly between groups. In conclusion, intensive intervention had substantial and significant impact on CF: evidence that behaviour-change interventions can be implemented at scale.

Bangladesh has made dramatic health advances for its population over the last two decades and is hailed as a remarkable health success story. However, rates of stunting and wasting remain high; in 2014 an estimated 36% of children were stunted and 14% wasted. Between 2011 and 2014 stunting reduced nationally by 4 percentage points (pp); wasting declined by only 1pp in the last 10 years. Appropriate infant and young child feeding (IYCF) practices are a critical component of optimal child growth and development. This includes exclusive breastfeeding until six months of age and the provision of safe and nutritionally rich foods in sufficient quantity in addition to breastmilk from 6 to 23 months of age. In Bangladesh, although rates of exclusive breastfeeding increased to an estimated 55% in 2014, there has been little to no progress in improving children’s diets, with only 23% consuming a minimally acceptable diet. There is currently little evidence available on what works to improve maternal knowledge and practices related to complementary feeding (CF), how these changes in turn lead to positive child outcomes, and what factors enable successful scale-up of these interventions.

This paper reports on findings from a cluster-randomised impact evaluation of an at-scale programme in Bangladesh. The objectives of the evaluation were to compare the impact of two ‘Alive and Thrive’ intervention packages on CF practices and anthropometric outcomes. The first intervention package involved intensified interpersonal counselling (IPC), a mass media campaign (MM), and community mobilisation (CM); the second package involved standard nutrition counselling, less intensive MM and non-intensive CM. The programme model reached a large scale, with an estimated 1.7 million mothers of children under two years old in 50 sub-districts.

Interventions

IPC (both intensive and standard) was delivered by a large non-governmental organisation (NGO) in 50 rural sub-districts through its existing countrywide essential healthcare programme. Standard IPC involved routine home visits through which information on IYCF practices were delivered. In intensive areas, a new cadre of nutrition-focused frontline workers conducted multiple age-targeted IYCF-focused counselling visits to households with pregnant women and mothers of children under two years of age, coached mothers as they tried out the practices, and engaged other family members to support the behaviours.

The MM component, implemented in both intensive and non-intensive areas, consisted of the national broadcast of seven television spots that targeted mothers, family members, health workers and local doctors with messages on various aspects of IYCF, three of which were focused on CF. In intensive areas with low electricity and limited access to television, local video screenings of the television broadcasts and other IYCF films produced by the project were used. In intensive areas, CM included sensitisation of community leaders to IYCF and community theatre shows focused on IYCF. In non-intensive areas, CM was less structured and covered general healthcare topics and did not include IYCF-related information.

Evaluation method

A cluster-randomised, non-blinded impact evaluation design was used to compare the impact of the two intervention packages. A cross-sectional household survey was conducted at baseline (2010) and exactly four years later (2014) in the same communities in households with children 0-47.9 months of age (n=600 children 6-23.9 months of age and n=1,090 24-47.9 months of age at baseline (2010); n=500 children 6-23.9 months and n=1,100 children 24-47.9 months at endline (2014)). Primary outcomes measured were CF practices in children 6-23.9 months of age and the prevalence of stunting in children 24-47.9 months of age. Five CF indicators were examined using 24 hour recall of the mother/caergiver: 1) minimum dietary diversity; 2) minimum meal frequency as appropriate for age and breastfeeding status; 3) minimum acceptable diet (defined as breastfeeding and achievement of numbers 1 and 2); 4) consumption of iron-rich or iron-fortified food; and 5) timely introduction of solid, semi-solid or soft foods. Anthropometric data were collected using standard methods by trained field staff. Difference-in-difference impact estimates (DDEs) were derived, i.e. the effect of the intensified versus standard programme adjusting for geographic clustering, infant age, sex, differences in baseline characteristics, and differential change in characteristics over time.

Results

Results showed that the groups were similar at baseline. The levels of all core WHO CF indicators improved over time (P < 0.0001 for all indicators) in both the intensive and non-intensive groups. For all CF indicators except timely introduction of solid, semi-solid, or soft foods, the increases were significantly higher in the intensive groups. The DDEs of programme impact were 16.3 pp, 14.7 pp, 22.0 pp, and 24.6 pp for minimum dietary diversity, minimum meal frequency, minimum acceptable diet, and consumption of iron-rich foods, respectively. All DDEs were statistically significant in adjusted models. Achieved levels of CF indicators in the intensive areas were high, ranging from 50.4% for minimum acceptable diet to 63.8% for minimum diet diversity, 75.1% for minimum meal frequency, and 78.5% for consumption of iron-rich foods. There was also a significant differential shift between groups from early and late introduction of water and other foods to a more well-timed introduction between the ages of 6 and 8.9 months. These programme impacts were large and significant, ranging from 16 to 39 pp for different foods. The shift was primarily from early to timely introduction for water, rice, and semi-solid foods, and from late to timely introduction for animal source foods (ASFs) and other foods.

Stunting declined significantly in children 24-47.9 months of age in both groups between baseline and endline, by 5.2 pp in the non-intensive and 6.3 pp in the intensive group. The declines in the prevalence of stunting did not differ between groups. A similar pattern was observed for the proportion of children classified as being underweight (decline of 5.2pp in the non-intensive, 6.6pp in the intensive) and wasted (decline of 1.4pp in non-intensive and 2.5 in intensive).

Conclusions

The results show that a programme providing intensified IPC, MM, and CM (the ‘Alive and Thrive’ intensive intervention) at scale had a substantial and significant impact on several CF practices in comparison with changes observed with a less intensive behaviour-change intervention in Bangladesh. Large-scale programme delivery was feasible and, with the use of multiple platforms, reached 1.7 million households. Although improvements in child growth were observed in both groups and for all age groups over time, the DDEs for linear growth and stunting at 24-47.9 months were not statistically significant and therefore cannot be attributed to the intensified interventions. The authors suggest that non-differential impacts on stunting were likely due to rapid positive secular trends in Bangladesh and the further acceleration of linear growth requires accompanying interventions. The authors conclude that this study offers compelling evidence that behaviour-change interventions can be implemented at scale to deliver impact on what remains a substantial global challenge: improving children’s diets.